question

Five major functions of the SKIN

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-protects underlying tissues -regulates body temperature -secretes sebum -transmits sensations through nerve receptors -produces and absorbs vitamin D from UV rays of the sun

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Factors influencing hygiene

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-personal preferences -culture, religion, spirituality -pain or discomfort: give meds 30 minutes before bath -decreased lack of motivation, weakness, fatigue -activity intolerance -sensory deficits: hearing, smell, lack of sensation -cognitive impairments -neuromuscular or musculoskeletal impairment -medically imposed restriction: bed rest, restraints, very ill -IV, CAST, etc -severe anxiety -emotional disturbances

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What should the nurse keep in mind when delegating hygiene?

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Make sure to communicate: -patient limitations -assistive devices -safety precautions -obstacles -observations PCA doesn't do assessment, nurses do!!!!

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What do I look for in Hygiene?

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-skin -hair -nails -oral cavity -assessing self-care abilities, patients activity tolerance, possible limitations

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Factors affecting skin

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-Dampness can cause breakdown -Dehydration can lead to slow healing -insufficient circulation: slow healing -nutritional status: slow healing -external devices: can rub against skin -positioning: can cause pressure ulcers

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Shearing forces

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-wears the skin over the bones -happens when you position the patient too high -prevent by not putting them in semi-fowlers

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What is the most common site for pressure ulcers?

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over bony prominences -check thoroughly

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Ecchymosis

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brusing

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necrosis

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rotting, death of tissue

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What to teach with patients who have diabetes?

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proper foot care

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What is the nurses role with absue?

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to report it

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Things that can happen with oral cavity?

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-halitosis: bad breath -dry mouth -ICU: ventilator associated pneumonia can happen from not cleaning the mouth out

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What do I do with hygiene?

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INTRODUCE SELF -safety and privacy: only expose what needs to be exposed -assess skin -prevent drafts -clean the clean spots first then the dirty ones -distal to proximal -barrier protection: catches heat and is a cream that acts like a barrier

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Complete bed bath

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Pt is on bed rest, so the nurse had to clean the patient and changes the sheets/bedding

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Self-help bath

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patients are able to clean themselves with little help from the nurses for washing their back and feet

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Partial bath

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cleaning only the areas that are odorous, feet, face, back, axillary, genitals, hands

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Bag bath

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washcloths in a bag with soap that clean each area of the body and are not to be reused

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Towel bath

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uses regular towels that are warm , wet, soapy towels

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Tub bath

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reduce the work of the nurse and allows the client to be independent

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Shower

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useful for ambulatory clients and minimal assistance from the nurse

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Therapeutic bath

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-given to soothe irritated skin or to treat an area -medications can be placed in the water for 20-30minutes

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What order to wash a patient?

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-face -arms and hands -chest and abdomen -legs and feet -back and perineum

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Bathing a patient with dementia

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-remember this is a person and not a task to complete -be flexible: do what they want to do -give options-allow patient to feel in control -be prepared: STOP if the patient becomes upset -ask for help

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Alopecia

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patches of lost hair

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Hirsutism

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excessive hair growth

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pediculosis

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lice -put patient on contract precautions -NIX is used as treatment

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For an unconscious patient, what patient should you put them in for oral care?

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sims position to let the fluid drain out

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Dentures

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-properly take care of -put them in a cup of warm water with patients name on it -never sit on a napkin

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Callus

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a thickened portion of epidermis, caused by pressure from shoes and use lanolin to help keep the skin soft and prevent the formation of calluses

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Corn

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a keratosis used by friction and pressure from a shoe, its circular and raised -prevented by wearing comfortable shoes

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unpleasant odors

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happen because of sweat

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plantar warts

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caused by papovavirus hominis virus -curettage the warts, freeze them or apply salicylic acid

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fissures

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deep grooves, occur between the toes as a result of dryness and crackling of the skin

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Tinea pedis

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ringworm of the foot causes by a fungus and is contagious

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ingrown toenail

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caused by improper trimming

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What do you as the nurse need to make sure before shaving a male patient or female patient?

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make sure they are not on any blood thinners that may make them bleed out

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Clients with diabetes should have their nails

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filed rather than cut

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periodontal disease

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gum disease

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dental caries

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cavities

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gingivitis

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red, swollen gingiva

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Clients at risk for diseases

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older, seriously ill, confused, comatose, depressed or dehydrated

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Dry mouth (xerostomia)

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can be from poor fluid intake, heavy smoking, alcohol use, high salt intake, anxiety, and medications (antihistamines, antidepressants, antihypertensives)

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edentulism

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lack of teeth

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other reasons why a client would experience xerostomia

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lack of O2 therapy, tachypnea, and NPO status

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Foley care

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proximal to distal clean cautiously

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the purpose of brushing and combing the hair

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-stimulates the circulation of blood in the scalp -distributes oil along the hair shaft -helps arrange the hair

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how often to shampoo hair

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based on the individual as needed

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Shaving

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-hold skin taut -hold it at 45 degree angle, shave in short, firms strokes in the direction of hair growth

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How to clean the eyes

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inner canthus to outer canthus

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Making a bed

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-unoccupied -occupied

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principles of making a bed

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-make it wrinkle free so there is not breakdown or abrasion -keep it dry -face the pillow away from the door

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Flat position

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-mattress is horizontal -maintains alignment for clients with spinal injuries -assist clients to move and turn in beds -allows the nurse to make the bed

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Fowlers position

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-45-60 degree angle -to promote lung expansion for client with respiratory problems -to assist the client to move to a sitting position on the side of the bed -for reading, eating, watching tv

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Semi-fowlers position

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-15-45 degrees -to promote lung expansion

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Trendelenburgs position

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-head of the bed is lowered and the door raising in a straight incline -to promote venous circulation -to provide postural drainage

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Reverse trendelenburgs position

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-head of the bed raised and the foot lowered -to promote stomach emptying and prevent esophageal reflux

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Body mechanics

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-the efficient, coordinated, and safe use of the body to move objects and carry out the activities of daily living -NEVER BEND AT THE WAIST -always raise bed to your level

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3 things of body mechanics

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-body alignment -body balance: one foot infant of the other (lunging), feet should be shoulder width apart -coordinated body movement (1,2,3)

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More things about body mechanics

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-increase stability -face the direction of movement -divide activity -reduce work load: no more than 30lbs -reduce friction -always use a draw sheet

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When moving someone from stretcher to bed what should the height of the stretcher be in comparison with the bed?

answer

the stretcher should be higher than bed, when moving them to bed; the stretcher should be lower than the bed when moving them from bed to stretcher

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Sims position

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side lying with foot across the other leg

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Supine

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back lying

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Lateral

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side lying

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Orthopneic

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lying against bed side table in a tripod position if patient has difficulty breathing

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Mobility

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is the ability to express oneself, satisfy basic needs, like ADLs and participate in recreational activities as desired

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How often to turn a patient in bed

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every 2 hours

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Mobility vs immobility

answer

-clean and dry -shift weight in chair every 15 minutes -support devices

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Nutrition for mobility

answer

-high protein diet -albumin 3.5-4.8g/dL -less than 3.5 indicates poor nutrition and may increase risk of poor healing and infection -may be parenteral (IV) or enteral (through GI system)

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In patient is vegan, what types of protein can they have

answer

tofu and beans

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What happens with immobility?

answer

-metabolic -respiratory -cardiovascular: increases workload of the heart -musculoskeletal -urinary/elimination: decreased Urinary output, and motility of elimination -integumentary: breakdown -psychological

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If patient does not get up and move around, what could happen?

answer

blood clots can form, loosing circulation and blood flow

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Nursing interventions for respiratory system

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-Turn, cough, deep breath every 2 hours -promote thoracic cavity expansion -maintain patent airway -prevent stasis of pulmonary secretions -atelectasis: collapse of lobe or of an entire lung -pneumonia: infection, immunity acquired, or from just sitting

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Nursing interventions for cardiovascular system

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-reduce orthostatic hypotension: when they sit up and BP drops, so move patient slowly, swing them side of the bed -reduce cardiac workload -prevent thrombus formation

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Nursing interventions for musculoskeletal

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-active ROM: the patient does it on their own -passive ROM: the nurse is doing it

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Nursing interventions for GI and GU

answer

FOLEY CARE

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bedside commode

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used for clients who can get out of bed but unable to walk to the bathroom

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bedpan

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females: use both a for urine and feces males: bedpan for feces and urinal for urine

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Fracture pan

answer

hip

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high back, and slipper pan

answer

for clients unable to raise their buttocks because of physical problems

Fundamentals of Nursing Hygiene and ADLs – Flashcards

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